Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and preventive lessons: (1) Police failed to investigate or escalate multiple warning signs of escalating violence and suicide risk despite a history of intimate partner violence, stalking, and explicit suicide threats on June 21 and July 14; (2) The 18 June forced entry into Ms Rankine's unit was misclassified as a minor matter rather than criminal trespass; (3) The 14 July police impersonation incident was handled as an ancillary (intelligence) report rather than a criminal incident report, preventing proper investigation; (4) Multiple opportunities for intervention occurred—particularly after 14 July when phone records could have linked Harding-Roots to the impersonation—yet no investigation occurred; (5) Early mental health and police coordination could have enabled risk stratification, restraining orders, and custody-based intervention during the critical 10-day pre-incident period.